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Hospital to HomeHospital to Home: A Care Transitions Project

A R MBA CMPEAnn Roemen, MBA, CMPE

Readmissions1 in 5 elderly patients Results in 2 3 million re hospitalizationsResults in 2.3 million re-hospitalizationsAnnual cost to Medicare - $17 billion +

Jencks SF,Williams MV,Coleman EA. Rehospitalizations Among Patients in the Medicare Fee-For-Service Program. NEJM 2009;360(14):1418-1428.

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CMS InitiativesPPACA –cut hospital pay by 1% if exceeding–

rate of readmission yet to be determinedrate of readmission yet to be determinedOctober 2012 – CHF – AMI – pneumonia2013 – 1%2014 – 2%2015 & Beyond – 3%

Add COPD, CABG, vascular surgeries

Estimated savings $7.1 - $8.2 billion over 10 yearsJuly 1, 2011 – beginning of initial performance period used to measure quality improvement

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Incentive Established! Collaborative Effort

HospitalsHospitalsPhysiciansClinicsHome HealthResearch Hospice

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Action PlanCoordinate weekly meetingsResearch other programsResearch other programsEstablish goalsDevelop protocolsEstablish pathwaysGet buy-in

Due DiligenceBegan studying other models

St Luke’s Hospital Cedar Rapids IASt. Luke’s Hospital, Cedar Rapids, IAHealthEast, St. Paul, MNBaylor Health Care System, Dallas, TX

IHI 5-part webinar series “Preventing Heart Failure Readmissions”

50% of patients leave physician’s office not understanding what they were told

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Common ThemesMedication management & educationDi ifi d tiDisease-specific education “Teach Back” at multiple levels of carePost-discharge appointmentInteraction with health care professional for 30 days post-discharge

GoalsPrimary goal Reduce readmissionsHospital Compare – primary CHFp p p y

Avera McKennan 21%Avera Heart Hospital of SD 23.5%

Chart Audit – primary and secondary CHFAvera McKennan 19.2%Avera Heart Hospital of SD 6.4%

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Board DiscussionReadmission rate not only measure of success

Medication ReconciliationMedication ReconciliationDays to follow up appointmentAssess understanding of CHF (teach-back methodology)Satisfaction

Interdisciplinary, multi-service level intervention to improve continuity of care, provide patients consistent tools and support to promote knowledge and self management of their disease

StrategiesStandardized patient education materialsImplementation of teach back protocolsImplementation of teach-back protocolsEstablish follow-up appointment standardsEducate clinic staff and physiciansComplimentary home visitFollow-up with patient for 30 days post-discharge

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Management Tools

Teach-Back MethodologyAssess understanding of discharge instructionsAssess understanding of discharge instructionsTraining Video

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Pil t P j tPilot Project

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Research FocusAll CHF Patients Evaluated and Categorized

Enrolled in the H2H programEnrolled in the H2H programEligible but not enrolled

Patient refuses and decides not to continue Possible palliative care or hospice eligible but patient refuses

ExcludedControl group: chart audit

Inclusions:Hospitalized at Avera McKennan or Avera Heart Hospital of SD

Research Focus

Hospitalized at Avera McKennan or Avera Heart Hospital of SD between June 2010 - June 2011Primary or secondary diagnosis of heart failureAge 18 years or olderMust be able to participate in the Informed Consent processGeographic area (greater Sioux Falls area)

Limited initially - expand to 40 mile radius

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Exclusions:ESRD

Research Focus

ESRDPatients going to long-term care, skilled nursing facility, rehabilitationExperiencing suicidal ideation within past 6 monthsBlind or deafUnable to speak EnglishWithout a phonePlanned hospital readmission scheduled within 30 days

EnrollmentProcess for Enrollment

Identify heart failure patients Evaluate for inclusions andIdentify heart failure patients. Evaluate for inclusions and exclusions. Patients do not have to be homeboundHeart Failure patients are given the “red folder” and staff educate using the “teach-back” method. Caregivers educated as appropriateCase Manager visits with the patient and gets order. If home health is ordered, patients are given a choice of agenciesCase Manager calls Interim Home HealthCase Manager calls Interim Home HealthCardiac nurse from Interim is the Transitional Care Coordinator

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H2H Program ProcessTransitional Care Coordinator visits with the patient in the hospital within 48 hours ofpatient in the hospital within 48 hours of admissionTransitional Care Coordinator makes complimentary home visit

Medication reconciliationHeart Failure Patient Education is reinforcedV ifi f ll i i dVerifies follow up appointment is madePatient is assessed for home health needs

Weekly follow up phone calls are made.

Statistics & FindingsStatistics & Findings

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Patients EvaluatedEnrolled – 100N E ll d 159Non-Enrolled – 159Exclusions - 829

Readmissions – All CauseEnrolled – 17%N E ll d 28%Non-Enrolled – 28%

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Readmissions for Heart FailureEnrolled – 5%N E ll d 11%Non-Enrolled – 11%

Medication Reconciliation Discrepancies Found – 22% of the time

Discharge Discrepancy – 10%Non-Filled Rx – 5%Undisclosed Rx at Home – 3%Noncompliance – 3%Financial Burden 1%Financial Burden – 1%

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Follow Up AppointmentPrior to study

Up to 4 6 weeksUp to 4-6 weeksJune – March

9.1 days

Teach Back EvaluationInitial Score – 62%Fi l S 99%Final Score – 99%

What weight gain should be reported to your doctor?

Can you give me at least 2 examples of symptoms to report to your doctor?

Can you give me at least 3 examples of high salt foods you should avoid?

Can you tell me the names of the medications you are taking for your heart?

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Patient Caregiver Knowledge/Satisfaction

How well do you understand your heart condition?condition?

Initial 3.81Final 4.30

Do you feel anxious, sad or lonely at home?Initial 3.72Final 3 98Final 3.98

Can you give me examples of food you should avoid eating?avoid eating?

Initial 3.28Final 3.92

How often do you weigh yourself & record your weight?

Initial 3 59Initial 3.59Final 4.86

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How well do you understand when/why to take prescribed medication?take prescribed medication?

Initial 4.13Final 4.45

How well do you understand problems to watch for/when to call the doctor or seek emergent care?emergent care?

Initial 3.96Final 4.30

How many minutes do you walk in a day?Initial 2 30Initial 2.30Final 3.06

How do you feel about the pilot program?Initial 3.43Final 3.76

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Lessons LearnedReadmission Rates can be significantly improved with a coordinated hospital to home programcoordinated hospital to home programChange mindset from “discharge” to “transition of care to another setting”

Challenges Some difficulties identifying patients earlyVariation with inclusion of secondary diagnosis heart failureVariation with expanded time frame and expanded geographic areaWhat can be done with excluded cases?Patient education/knowledge does not always end in complianceFactors include motivation, financial issues, support, etc

Expanding H2H

Expansion:System wideSystem-wideIncluding current exclusionsCOPDOther

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From This - 40 mile Radius

To This: 300 Locations, 97 Communities, 5 States

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ObjectivesMaintain integrity of program while recognizing differences in communitiesdifferences in communities

Key participantsWho is the transitional care coordinator24/7 calls

Establish baseline for measurementH2H Champion

Tool KitProgram materials

Required vs optionalRequired vs. optionalEducational materials Teaching methodsDischarge OrdersCommunication

ScriptingScriptingPower Point presentationsEmail Newsletter articles

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Identifying patientsEHR h i i d “ f l t H2H”EHR – physician orders “referral to H2H”Data Collection/Aggregation

Baseline auditCapturing data points – who/how

Keys to SuccessUniformity among hospitalsPh i i i l tPhysician involvementCommunity involvementGeneric design – applicable to other chronic diseases